For the last three years, Joanna Field, BSN, RN, has been a grant and per diem RN case manager, a title that only begins to describe the work she does daily to provide care to some of the most destitute veterans of the U.S. Armed Forces seeking medical care at the VA Greater Los Angeles Healthcare System in west L.A.
And that work, she said, doesnt necessarily end when patients are discharged and sent home, as, for her, many of her patients might have no real home to which they can be sent.
One of my greatest challenges comes when patients are discharged from the hospital and deemed stable for returning home, Field said. Many of the physicians dont understand what home means to the homeless. Things to consider after discharge include whether one may need assistive devices, wound care or assistance with (daily living activities). There is so much more to consider than stable vital signs.
Since assuming her job three years ago, Field has joined the fast-growing ranks of case management nurses.
While case managers have served in healthcare for more than a century, the demand for case management services has surged in recent decades. As the managed care paradigm has become the norm in the U.S. healthcare system, the need has grown for specialists to help patients receive the best care possible, while maximizing efficiencies and controlling costs.
Jeff Frater, BSN, RN, worked as a case management nurse in the mid-1990s, and in the ensuing years, served in virtually every case management setting possible, including acute care, rehabilitation and managed care. He now serves as director of partner development at TCS Healthcare Technologies in Auburn, Calif., working with hospitals and other organizations to manage their case management software.
Case management is what kept me in nursing, Frater said.
In just his years of nursing, Frater said, not only the duties and opportunities, but also the perception of case managers in the health care industry have profoundly shifted, moving from outright hostility in some settings to general appreciation of case managers work in helping patients better understand the intricacies of modern healthcare and in the process improve outcomes.
Frater said case managers are at their best when helping others who might be at their lowest points, in the throes of health or family crises.
In recent years, after the death of his sister following an illness, Frater sat across a table from his brother-in-law, helping him navigate through a stack of medical bills and other paperwork left from his wifes treatment.
The death of his wife was traumatic and life-altering enough, Frater said. But I realized not everyone has a brother-in-law who works with this stuff every day.
He said it is that level of service, and of empathy, effective case managers should employ on the job every day.
Effective case managers have an understanding of all aspects of the healthcare system, Frater said, including the finances of healthcare.
Its important to talk about the money, he said.
Candice Krill, MS, MBA, RN, ACM, president-elect of the Illinois State Chapter of the American Case Management Association, now serves as director of quality at Northwestern Lake Forest Hospital near Chicago, helping to oversee that hospitals case management nurses, among other duties.
From 2000-2005, Krill served as director of the case management program at the then-Illinois Masonic Medical Center in Chicago, a program she helped develop and implement.
As understanding of population health and preventive care continues to evolve, Krill said, case management nurses will have a significant role in responding to the challenges and an increased opportunity to impact the American healthcare system.
We are in the unique position of understanding finance, clinical care and care beyond the walls of the hospital, Krill said.
She said the role of the case manager continues to evolve and develop, moving out of the hospital and into the community, as case managers now work to help patients not only while they are in the hospital, but also to ensure they obtain the services they need well beyond discharge.
Case managers must fully understand all of the resources available in the community transportation services, pharmacy services, community support services in order to manage the patients transition to the next level of care, Krill said. Members of the health care team now manage transitions of care and patients are never really discharged or gone.
At Greater L.A., Field said, it was precisely that aspect of case management that drew her to the field after three years as a bedside nurse.
After developing long-term therapeutic relationships with these guys, I was interested in knowing where they went, and what would become of them post-discharge, Field said.
In the years since, Field said, she has learned many of her patients challenges only begin with immediate medical needs, leading her and her fellow case managers to reach out to colleagues and other agencies to help patients overcome the need for housing, home health nursing services and help for substance abuse and mental health concerns.
The challenges are as different as the individuals themselves, Field said. You just have to take what you have learned from past experiences and learn to be creative with new experiences.